a client has been prescribed lithium for bipolar disorder which of the following should the nurse teach the client to monitor for signs of toxicity
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B

1. A client has been prescribed lithium for bipolar disorder. Which of the following should the nurse teach the client to monitor for signs of toxicity?

Correct answer: C

Rationale: The correct answer is C: Tremors. Lithium toxicity can present with symptoms such as tremors, nausea, and blurred vision. Tremors are a common early sign of lithium toxicity and should be monitored closely. While nausea and vomiting can also occur with lithium toxicity, tremors are more specific to lithium toxicity. Increased urination is not typically associated with lithium toxicity, and blurred vision is less common compared to tremors in this context.

2. A nurse is preparing to assist a provider with the insertion of a nontunneled percutaneous central venous catheter into a client’s subclavian vein. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take when assisting with the insertion of a nontunneled percutaneous central venous catheter into the subclavian vein is to place the client in Trendelenburg position. This position helps distend the veins and reduces the risk of air embolism during the insertion procedure. Option A, positioning the client in a high-Fowler’s position, would not be appropriate as it does not facilitate venous distention. Option C, placing a rolled towel under the client’s neck, is not directly related to the procedure and does not serve a specific purpose in this context. Option D, assisting the client into a side-lying position, is also not the correct choice as Trendelenburg position is preferred for this procedure to aid in vein distention.

3. A healthcare provider is assessing a newborn who is 48 hours old and is experiencing opioid withdrawals. Which of the following findings should the healthcare provider expect?

Correct answer: B

Rationale: The correct answer is B: Moderate tremors of the extremities. In newborns experiencing opioid withdrawals, moderate tremors of the extremities are a common sign. Other signs of opioid withdrawal in newborns may include irritability, feeding difficulties, and gastrointestinal disturbances. Choice A, hypotonia, is not typically associated with opioid withdrawal in newborns. Choice C, an axillary temperature of 36.1°C (96.9°F), falls within the normal range for newborns and is not specifically indicative of opioid withdrawal. Choice D, excessive crying, is not a typical sign of opioid withdrawal in newborns.

4. A nurse is caring for a client in active labor. The nurse notes variable decelerations in the fetal heart rate. Which of the following is the priority nursing action?

Correct answer: B

Rationale: The correct answer is to reposition the client. Variable decelerations are often caused by umbilical cord compression. Repositioning the client can help alleviate pressure on the cord and improve fetal oxygenation. Administering oxygen may be necessary in some situations, but repositioning the client takes precedence to address the underlying cause of variable decelerations. While preparing for delivery is important, addressing the immediate concern of variable decelerations by repositioning the client is the priority. Increasing IV fluids is not the priority in this situation as it does not directly address the cause of variable decelerations.

5. A client presents with symptoms suggestive of rheumatoid arthritis. Which of the following laboratory tests should be ordered to confirm this diagnosis?

Correct answer: B

Rationale: Rheumatoid factor is a specific marker for rheumatoid arthritis. It is often elevated in clients with this autoimmune condition, helping to confirm the diagnosis. Erythrocyte sedimentation rate (ESR) and antinuclear antibody tests can be supportive but are not specific for rheumatoid arthritis. Serum calcium levels are not typically used to confirm this diagnosis.

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